Dark Circles, At A Glance
- Best Results1-5 sessions, variable results
- Treatment RecoveryImmediate
- Procedure Time10- 30 minutes
- Skin SpecialistDavin Lim, Nurse
- Duration of ResultsVariable
- Back to WorkImmediate
Dark Circles - Eye Rejuvenation
This common skin concern is one of the most complex entities dermatologists deal with as there are many causes of dark circles. In some cases, treatments can be straight forward – dermal filler is an example. In others, it is complex, namely exclusion of allergens & irritants. Read more for an accurate guide as to how I approach dark circles– understanding the causes will lead to effective solutions.
FactsFacts on Dark Circles
- Dark circles can be due to over two dozen skin conditions
- Most patients will have at least two associated causes of dark circles
- A directed approach addressing the cause will give better results than ‘tying’ treatments
- Lasers including pico & dermal toning can reduce pigment
- Dermal fillers can address deep tear troughs
- Creams can be marginally effective for treating vascular & pigment causes
- Caffeine, peptides, vitamin K & arbutin are actives to look for in skin care
- In some cases, allergy testing via a medical dermatologist is required
What causes dark circles?
There are many causes of dark circles including genetic, physiological, post-inflammatory, age related laxity, anatomical, vascular, & in most cases a combination of the above. Treatment is aimed at addressing the actual cause.
What treatments are available?
In many cases treatments can help improve skin quality, volume, and integrity of the upper and lower eyelid skin. This, in turn, can improve dark circles and shadowing. I employ dermal fillers, lasers, surgery, energy devices and in some cases topicals to address various causes.
How can dermal fillers help?
Dermal fillers can hide shadows from a deepened tear trough. Fillers do not change ‘pigmentation’. In cases whereby troughs are anatomically suitable, dermal fillers consisting of hyaluronic acid can help. In some cases, building up the support of the lower eyelid – eye bags can help hide dark circles. This involves dermal fillers to the rim of the eye before actually treating the trough itself.
I normally perform 2 sessions, separated by at least a week. The first is to build support, the second is to add volume to the deep troughs.
I use cannula technique in this area. Treatments are comfortable with little downtime. It is important to stop any potential medications that may cause unwanted bleeding or bruising during the filling process. This includes fish oil, high dose vitamin E, aspirin and anti-inflammatories. You should avoid exercise of 48 hours post dermal fillers.
In the context of ‘dark circles’, dermal fillers can give a 25-30% ‘correction.’ More on how I perform this procedure in the dermal filler section of this website, under ‘tear troughts.’
How can laser resurfacing help?
Lasers including Fraxel & LaseMD fractional resurfacing, CO2 & erbium can help in some cases of dark circles related to poor skin texture and/or skin laxity.
Skin type 1-2 (fair skin patients) respond the best. Lasers work by tightening skin through remodelling of collagen & elastin, in addition to removing sun damage (elastosis).
For darker skin patients (skin type 3+), my go to devices include pico lasers & RF energy devices.
Remember, lasers and energy devices only tighten. Volume replacement can only be achieved with dermal fillers or fat transfer.
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What lasers do I use in darker skin types?
For dark circles in darker races, including Asian skin, my go to laser is the Pico laser. I prefer the 1064 nm wavelength over the 755 Alex wavelength of Picosure because the former penetrates deeper, has a better safety profile & gives superior results with less pain & downtime.
Pico laser treatments have zero downtime. Most cases require 2-5 sessions over a period of 2-4 months. Other lasers I employ in darker skin patients include QSL nano laser using the Spectra.
Can microneedling help reduce dark circles?
Microneedling can be marginally effective in some, however it can frequently worsen this condition. This is why I prefer treatments that do not break the skin’s surface such as pico or nano lasers.
Skin needling works by breaking the upper layers of the skin through a process called micro-injury. This leads to CIT or collagen induction therapy. As the skin of the eyelid is the thinnest on the face, this often leads to bleeding under your skin. This leads to post treatment purpura or bruising. Over time the iron in blood cells can stain the skin.
I am not against microneedling as I frequently use this technique on a daily basis to deliver CS into the deep layers of the skin, I just do not advocate this treatment for delicate areas of the undereye.
Why don’t I treat dark circles with microneedling or PRP?
I acknowledge that microneedling can be effective in some patients. The question is, are there procedures that are less risky?
Microneedling the eyelid area can lead to purpura, namely bleeding under the thinnest skin on the body. In the context of PRP or autologous blood – platelets (Platelet Rich Plasma), there is a consensus that this treatment is effective for joint & hair loss. It can also help marginally with recovery from other porcedures.
PRP does not give volume, nor does it consistently improve skin quality (including dark circles & under eye rejuvenation). The initial results are from swelling of the area. This photographs well, as wrinkles are less. This result can be replicated with injections of saline water. After the swelling of a series of PRP injections settles down, there is minimal, if any changes to the under-eye areas. In some patients, dark circles are actually worse (due to bleeding under the skin).
A more reliable, less risky procedure is under eye or tear trough dermal fillers. This procedure takes 2-3 minutes to perform, does not cause bleeding & in most cases gives a predictable increase in volume with a subsequent decrease in wrinkles. For patients with a tear trough, it decreases shadowing.
Can surgery help reduce dark circles?
Surgery is indicated if there is significant laxity of the lower eyelids, or if there is significant fat herniation. Partial removal of ‘eye-bags’ can give a good outcome if there is pathology. This procedure is best conducted by an eye surgeon.
Can Ultherapy be used for dark circles?
HIFU or high intensity ultrasound using Ultherapy can help treat laxity in some cases. I used to employ this treatment in the past, however I find that RF (see below) is more useful in the orbital area (on-label) vs off-label Ultherapy. Ultherapy is best used in the lower face areas to treat jowls & wrinkles.
How can radiofrequency help?
Devices such as Thermage, RF Pelleve, Tempsure & others can help improve laxity in some patients, especially in ethnic skin. By gently heating skin to 62-65 degrees internally, we can achieve tightening of eyelid skin. This can reduce shadows around the orbital area. Most patients require 2-4 sessions depending on age, ethnicity and clinical presentation. I also combine RF with lasers & dermal fillers.
*RF is only suitable for some forms of skin laxity & dark circles. It works best in mild to moderate laxity, in patients age 30-mid 50s with little sun damage.
What is the best cream for dark circles?
Topical creams do not give a reliable outcome in the management of dark circles, however there are some exceptions-
For vascular causes of dark circles, topical creams that contain argan oil, caffeine, peptides, & vitamin K can help modulate blood flow. Most skin care companies will have their own range.
A well noted brand of eye cream is made by Allegan (the manufacturer of Botox). This eye cream is called TNS Eye Cream (RRP $130 USD – 180 USD). TNS has the potential to modulate blood flow in some patients. Another more cost-effective solution is Swisse Anti- Aging Eye cream, priced at $9-14 USD. I have no preference as to the brand.
Eye creams that contain retinol may also help with wrinkle prevention. The downside with retinoids around the eyes is that they can cause skin irritation. Hence it is best to use a conservative strength cream, ideally 0.25 to 0.5%. Formulations matter, especially around the eye area.
Here are some skin care actives that may help some forms of dark under eye circles.
- Hyaluronic acid; acts as a moisturiser & humectant. Good for dry-sensitive skin
- Retinol; can improve collagen & may marginally improve some cases of vascular-thin skin
- Caffeine is a well known modulator of blood flow. It can help some cases of dark circles due to vascular causes
- Vitamin K; as above
- Peptides; these are frequently added to more expensive creams. In theory may increase collagen production, in practice, questionable
- Argan oil; acts as an agent to reduce pigmentation, tyrosinase inhibitor
- Niacinamide or vitamin B3; acts as an anti-inflammatory agent. One of the safer skin care actives on the market
- AHAs including glycolic, lactic, and citric acids; can exfoliate skin cells. These can be formulated in very weak concentrations in some eye creams; esp citric acid
- Botanicals such as green tea, bearberry, licorice can act as antioxidants as well as pigment inhibitors
- Vitamin E or tocopherol is an antioxidant; generally banal as an eye cream
When are medical treatments indicated?
Dark circles can be secondary to inflammation, a term called PIH or post inflammatory hyperpigmentation.
PIH can be due to atopic dermatitis – atopic eczema or contact dermatitis. Contact dermatitis is most often irritant rather than allergic. In some cases, medical patch testing may be indicated. If you have symptoms such as itch or irritation and eyelid concerns, your first port of call is a medical dermatologist as you will benefit from medical intervention prior to physical therapy (such as lasers, peels, surgery or fillers etc.).
What are genetic or hereditary causes of pigmentation?
Genetic causes include constitutional or physiological pigmentation as well as pigmentation demarcation lines (V or W lines- F and G type classification). In most cases there is a family history. Races including Indians, Sri Lankans, Middle Eastern & Asians are prone to this type of ‘dark circles.’
Constitutional pigment presents as dark area of the upper & lower eyelids with continuity of pigment. PDL or pigmentary demarcation lines are harder to spot. They present as well demarcated lines from the orbital rim, extending to the cheeks on both sides. Again, they are more commonly seen in darker races.
For inherited causes of pigmentation, there are no ideal solutions. All treatments to date do not give a predictable response.
I can prescribe low dose laser, however I may only get 10-30% lightening after 5-10 sessions. The most important concept to understand is that patients should NOT use potential irritants or allergens making PIH worse.
A few pointers for constitutional dark circles–
- Do not use high concentrations of bleaching agents, these can result in post inflammatory hyperpigmentation.
- Do not attempt microneedling or microneedling-PRP as this can lead to bruising and make pigment worse (post-purpuric pigmentation).
- Dermal fillers have no impact on this form of dark circles. Dermal fillers can only lighten the shadows of deep tear troughs.
What can be done for post-inflammatory hyperpigmentation?
For pigmentation causes of dark circles due to increased melanin (post inflammatory hyperpigmentation) & due to bleeding (post procedure prupura), my treatment of choice is with a pico laser.
Pico lasers can speed up resolution of pigment by a factor of 5 times. Most patients require between 2-4 sessions over 4-10 weeks.
Do I use fat transfer- nano fat under the eyes?
No, not unless you have a HUGE volume deficit. The primary reason is the predictability or rather the lack of, with fat. This includes nano-fat & adipose stem cells. For the latter, a really simple low cost, low downtime laser or Tixel can give much better results than stem cells.
I primarily use fat to correct large volume deficits; examples include age related volume loss, surgical volume loss & atrophic acne scars. Usually, these volume deficits measure 10-30 ml. In this situation the use of autologous fat makes more sense compared to the same amount (volume) of dermal fillers. The downside of fat is the lack of malleability & predictability (even in the age of Lipo-Cube processing & fat washing systems).
Treating Dark Circles- Davin’s Viewpoint
This is one of the hardest algorithms to understand as there are many causes of pigmentation. The most frequent clinical presentations include two, or more concomitant causes. The most important aspect of managing dark circles is to not make this condition worse, which commonly happens.
An accurate diagnosis is essential. For genetic causes, marginal improvements can be made by addressing any shadowing, especially a deep trough. Skin irritation such as itch due to atopic or irritant dermatitis should be addressed with avoidance of irritants & potential allergens. If the latter is suspected, simple patch testing-allergy testing by a medical dermatologist will reveal the culprit/s.
Lasers can be useful if there are pigment & or vascular causes. QSL & pico lasers can give some responses to secondary causes of pigment, such as post inflammatory hyperpigmentation & marginal improvements in cases of physiologic pigmentation. Simple vascular lasers such as pulse dye laser can treat vascular congestion, especially on the lower eyelid. Larger periorbital veins that can contribute to ‘blue skin’ can be treated with long pulse Nd Yag lasers.
I frequently perform dermal fillers for the tear trough area in individuals with a tear tough deformity (harsh word to describe). In some cases, filler is straight forward. In cases where there is volume loss, I build up the orbital area and mid cheek before trough filling. My go to filler is a low-density hyaluronic acid filler, however in patients with really thin skin I do use calcium hydroxyl apatite fillers in a hyper dilute solution to avoid Tyndall to the area.
In the context of fat transfer, I tend to avoid this area, even with nano-fat & adipose stem cells. Reason being that overcorrection is frequently seen. Fat is great for large volume deficits (over 10 ml), I do not like fat in the under-eye area mostly because it is not as malleable nor as predictable as HA dermal fillers.
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